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Abstract
BackgroundIn Pakistan, where gendered norms restrict women's mobility, female community health workers (CHWs) provide doorstep primary health services to home-bound women. The program has not achieved optimal functioning. One reason, I argue, may be that the CHWs are unable to make home visits because they have to operate within the same gender system that necessitated their appointment in the first place. Ethnographic research shows that women’s mobility in Pakistan is determined not so much by physical geography as by social geography (the analysis of social phenomena in space). Irrespective of physical location, the presence of biradaria members (extended family) creates a socially acceptable ‘inside space’ to which women are limited. The presence of a non-biradari person, especially a man, transforms any space into an ‘outside space’, forbidden space. This study aims to understand how these cultural norms affect CHWs’ home-visit rates and the quality of services delivered.DesignData will be collected in district Attock, Punjab. Twenty randomly selected CHWs will first be interviewed to explore their experiences of delivering doorstep services in the context of gendered norms that promote women's seclusion. Each CHW will be requested to draw a map of her catchment area using social mapping techniques. These maps will be used to survey women of reproductive age to assess variations in the CHW's home visitation rates and quality of family planning services provided. A sample size of 760 households (38 per CHW) is estimated to have the power to detect, with 95% confidence, households the CHWs do not visit. To explore the role of the larger community in shaping the CHWs mobility experiences, 25 community members will be interviewed and five CHWs observed as they conduct their home visits. The survey data will be merged with the maps to demonstrate if any disjunctures exist between CHWs’ social geography and physical geography. Furthermore, the impacts these geographies have on home visitation rates and quality of services delivered will be explored.DiscussionThe study will provide generic and theoretical insights into how the CHW program policies and operations can improve working conditions to facilitate the work of female staff in order to ultimately provide high-quality services.
Highlights
In Pakistan, where gendered norms restrict women's mobility, female community health workers (CHWs) provide doorstep primary health services to home-bound women
The study will provide generic and theoretical insights into how the CHW program policies and operations can improve working conditions to facilitate the work of female staff in order to provide high-quality services
The concept of minimally trained CHWs as health care providers is a subject under intense debate
Summary
In Pakistan, where gendered norms restrict women's mobility, female community health workers (CHWs) provide doorstep primary health services to home-bound women. Most programs were gradually phased out in Africa and Latin America [10], they remained a common policy and programmatic response in South Asia, mainly because women’s seclusion, widespread in this context, is a key barrier to their travel to health and family planning facilities [11]. One such program is the National Program for Family Planning and Primary Health Care in Pakistan, known as the Lady Health Worker (LHW) program. Program coverage is about 50-60% of rural areas and urban slum populations [12]
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